Job Stressors and Mental Health A Proactive Clinical

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 Job
Stressors
and Mental Health
A Proactive Clinical Perspective

Karen Belkić, M.D., PhD

Adjunct Professor of Preventive Medicine
Physician Specialist in Internal Medicine

Čedo Savić, M.D., PhD

Primarius Attending Physician
Physician Specialist in Neurology and Psychiatry

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NEW JERSEY • LONDON • SINGAPORE • BEIJING • SHANGHAI • HONG KONG • TA I P E I • CHENNAI

8914_9789814525558_tp.indd 2 26/7/13 12:02 PM

Published by
World Scientific Publishing Co. Pte. Ltd.
5 Toh Tuck Link, Singapore 596224
USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601
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Library of Congress Cataloging-in-Publication Data

Belkic, Karen, 1952– author.
Job stressors and mental health : a proactive clinical perspective / by Karen Belkic,
Cedo Savic.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-9814525558 (hardcover : alk. paper)
I. Savic, Cedo, author. II. Title.
[DNLM: 1. Stress, Psychological--Case Reports. 2. Burnout, Professional--psychology--
Case Reports. 3. Job Satisfaction--Case Reports. 4. Mental Disorders--etiology--Case Reports.
5. Occupational Diseases--prevention & control--Case Reports. 6. Work--psychology--
Case Reports. WM 172.4]
RC454
616.89--dc23
2013021399

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library.

Copyright © 2013 by World Scientific Publishing Co. Pte. Ltd.

All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means,
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Printed in Singapore
 Dedication

This book is dedicated to our patients and to our colleagues, physicians,

towards a healthier working life.

v
May 2, 2013 14:6 BC: 8831 - Probability and Statistical Theory PST˙ws

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 Contents

Dedication……………………………………………………….... v
Preface ………………………..…...……………………………… xvii
Acknowledgements…...…………………………………….…….. xix
List of Panels and Table…...…………………………………...…. xxi
List of Figures….…………………………………………………. xxiii

Chapter 1 Work as a Potential Source of Meaning versus of

Stress: Implications for Mental Health……………….. 1
1.1 The need for an integrative clinical approach…………. 2
1.1.1 Preventing and overcoming demoralization: a
critical task………………..…………………... 3
1.2 Insights from cognitive neuroscience…………………. 3
1.2.1 Work stressors vs. the stress response: a key
distinction………………..…………………..... 4
1.3 The aims and organization of this book……………….. 4

Part I  Background: Evidence, Mechanisms, Current

Standard of Care and Methodology……………...…. 7

Chapter 2 The Work Environment’s Impact on Mental Health:

Epidemiologic Evidence………………………………. 9
2.1 Sociological models to assess the association between
the psychosocial work environment and health
outcomes………………………………………………. 9
2.1.1 Job strain……………………………………… 10
2.1.2 Effort reward imbalance………………………. 12
2.2 The work environment and mental health outcomes….. 13
2.2.1 Depression, burnout and related mental health
disorders………………………………………. 14
2.2.2 Suicide risk……………………………………. 18
2.2.3 Anxiety disorders……………………………... 19

vii
viii Contents

2.2.4 Occupations at risk for adverse mental health

outcomes……………………………………… 21
2.3 Neurological disorders, cognitive function,
cerebrovascular disease and work-related exposures…. 27
2.3.1 Headache……………………………………… 27
2.3.2 Epilepsy……………………………………….. 27
2.3.3 Cognitive function and work hours…………… 29
2.3.4 Neuropsychiatric consequences of
physical/chemical exposures………………….. 29
2.3.5 Occupational groups at risk for cerebrovascular
disease………………………………………… 30
2.4 Unhealthy behaviors associated with work stressors….. 30
2.4.1 Smoking………………………………………. 30
2.4.2 Obesity………………………………………... 32
2.4.3 Alcohol and drugs…………………………...... 33
2.4.4 Combined lifestyle related risk profile……….. 33
2.4.5 Absenteeism and presenteeism……………….. 34
2.5 Other health outcomes related to the work environment 35
2.5.1 Coronary heart disease, hypertension, other
cardiovascular disease………………………… 35
2.5.2 Peptic ulcer disease and diabetes mellitus……. 39
2.5.3 Vulnerability to malignancy…………………... 39
2.5.4 Musculoskeletal disorders…………………….. 41
2.6 Mental health consequences of job insecurity,
precarious employment, unemployment and retirement 42

Chapter 3 Work Stress Mechanisms and Mental Health:

A Focused Overview………………….………………. 47
3.1 Gender, work stressors and health: a richer
conceptualization……………………………………… 47
3.2 Econeurologic mechanisms: mental burden of work
processes………………………………………………. 49
 Contents ix

3.2.1 A deeper understanding of psychological

demands……………………………………….. 50
3.2.2 Emotional dimensions of work……………….. 66
3.3 Burden upon mental resources and the recovery
process………………………………………………… 73
3.3.1 The role of cognitive appraisal………………... 74
3.4 Event-related potentials, quantitative EEG and
neuropsychiatry………………………………………... 76
3.4.1 Anxiety………………………………………... 77
3.4.2 Post-traumatic stress disorder………………… 80
3.4.3 Depression, burnout and related disturbances… 81
3.4.4 Bipolar disorder……………………………….. 83
3.4.5 Psychoses……………………………………... 84
3.4.6 Migraine headache……………………………. 85
3.4.7 Epilepsy………………..……….……………... 86
3.5 The environmentbraincardiovascular system:
econeurocardiology…………………..…..……….…… 89
3.5.1 The glare pressor test…………...…………….. 90
3.5.2 Further directions…………...……………........ 98

Chapter 4 Work Fitness and Occupational Rehabilitation:

The Current Standard of Care…………...……..…… 101
4.1 Mental health disorders, work fitness and
rehabilitation…………...……………......................... 101
4.1.1 General observations…………...………..….. 101
4.1.2 Explicitly stressrelated mental health
disorders…………...………………………... 104
4.1.3 Anxiety disorders…………...………………. 107
4.1.4 Depression…………...………………........... 108
4.1.5 Bipolar disorders…………...……………….. 109
4.1.6 Psychotic disorders…………...…………….. 110
4.1.7 Alcohol and drug misuse……...……………. 110
x Contents

4.2 Neurological disorders…………….………………... 110

4.2.1 Migraine headaches……….………………... 111
4.2.2 Epilepsy……….………………..................... 111
4.2.3 Disorders of sleep and awareness................... 113
4.2.4 Disorders related to neurotoxicity exposure... 114
4.2.5 Cerebrovascular disorders............................... 114
4.2.6 Brain tumors……….……………….............. 114
4.3 Experience regarding work fitness and rehabilitation
from other areas of medicine.……………….............. 115
4.3.1 Oncology……….……………….................... 115
4.3.2 Ischemic heart disease and hypertension…… 117
4.3.3 Rheumatologic/musculoskeletal disorders..... 120
4.3.4 Diabetes, peptic ulcer disease and other
gastrointestinal disorders……........................ 122
4.3.5 Respiratory disorders…….............................. 124
4.4 Special issues for work fitness and occupational
rehabilitation……........................................................ 126
4.4.1 Further considerations about public safety..... 126
4.4.2 Women, work fitness and return to work…... 129

Chapter 5 The Occupational Stressor Index (OSI):

A Comprehensive Model derived from
Cognitive Ergonomics for Clinical Practice................ 131
5.1 Basis and organization of the OSI…........................... 132
5.1.1 The axes of the OSI: formation of a two-
dimensional matrix…..................................... 132
5.1.2 The OSI model in its entirety.......................... 143
5.2 The occupation-specific OSI instruments................... 145
5.2.1 Generic versus occupation-specific
instruments….................................................. 145
5.2.2 The process of developing occupation-
specific OSI’s….............................................. 146
 Contents xi

5.2.3Available occupation-specific OSI’s and

those in development...................................... 150
5.3 Reliability of the OSI.................................................. 150
5.4 Validity of the OSI...................................................... 152
5.4.1 Construct validity of the OSI:
theoretical/biological coherence..................... 152
5.4.2 Face validity of the OSI …….……………… 153
5.4.3 Criterion validity of the OSI: empirical
results ……..................................................... 154
5.4.4 Clinical validity of the OSI ………………… 159

Part II  The Clinical Case Studies………………..…………… 163

Chapter 6 Introduction to Part II: The Clinical Case Studies….. 165

6.1 A brief recapitulation………………………………... 165
6.2 Aims, scope and organization of part II..…………… 165
6.2.1 The structure of the clinical case studies…… 166

Chapter 7 An Exhausted Psychiatrist Thinking about Suicide:

Our First Clinical Case Study……………………….. 169
7.1 The case: Dr. R is extremely fatigued and admits to
thoughts of suicide……………………………...…… 170
7.1.1 Objective findings…………………………... 171
7.1.2 Initial assessment, management and clinical
course…………………………...................... 171
7.1.3 Additional psychometric and
neurophysiologic evaluation………………... 172
7.2 Dr. R’s case re-visited: insights from the OSI………. 172
7.3 How to proceed? Return to healthier work with
bolstered coping strategies………………………….. 176
7.3.1 Immediate steps……………….……………. 177
7.3.2 Step IIcognitive/behavioral therapy
focusing on psychosocial work stressors….... 179
xii Contents

7.3.3
Step IIIoutreach: initial efforts towards
improving work organization…………..…… 181
7.4 Comments and further thoughts…………………….. 183

Chapter 8 Middle-School Teacher with Panic Attacks and

Migraine Headaches: Second Case Study…..………. 185
8.1 The case: M.A.’s panic attacks and severe migraines. 186
8.1.1 Objective findings…………………………... 186
8.2 M.A.’s work situation: insights from the OSI………. 188
8.3 M.A. meets with the occupational neuropsychiatrist.. 191
8.3.1 Assessment………………………………….. 191
8.3.2 Therapeutic measures: cognitive-behavioral
therapy, immediate work-related and
lifestyle changes and pharmacotherapy…….. 191
8.3.3 Outreach: initial efforts towards improving
work organization…………………...……… 194

Chapter 9 Computer Programmer with Epilepsy and

Agoraphobia: Third Case Study…………………….. 197
9.1 The case: S.P.’s epilepsy and agoraphobia………….. 198
9.1.1 Objective findings…………………………... 199
9.2 S.P.’s work situation: insights from the OSI………... 200
9.3 S.P. meets with the occupational neuropsychiatrist… 203
9.3.1 Assessment………………………………….. 203
9.3.2 Integrative therapeutic approach: supportive/
cognitive-behavioral therapy, disclosure and
targeted workplace modifications…………... 204
9.4 The outcome……………………..………………….. 206

Chapter 10 Oncology Nurse with Breast Cancer and

Disturbed Sleep: Fourth Case Study..……………. 207
10.1 The case: C.G. has breast cancer and disturbed
sleep……………………..……………………….. 208
10.1.1 Objective findings…………………….. 209
 Contents xiii

10.2 C.G.’s work situation: insights from the OSI…….. 210

10.3 C.G. meets with the occupational neuropsychiatrist 213
10.3.1 Assessment…………………………….. 214
10.3.2 Integrative therapeutic approach:
supportive/cognitive-behavioral therapy,
disclosure and targeted worksite
modifications…………………………... 215
10.4 Comment………………………..………………... 216

Chapter 11 Control Panel Worker with Paranoid Ideation:

Fifth Clinical Case Study…..…………………….. 219
11.1 The case: T.S. mistrusts his entire work collective 220
11.1.1 Objective findings……………………... 220
11.2 T.S.’s work situation: insights from the OSI…….. 222
11.3 Intervention by the occupational neuropsychiatrist 226
11.4 Further thoughts and comments….………………. 226

Chapter 12 Tram Driver with Post-traumatic Stress Disorder:

Sixth Case Study….……………………………… 227
12.1 The case: B.F. has post-traumatic stress disorder... 228
12.1.1 Objective findings……………………... 229
12.2 B.F.’s work situation: insights from the OSI…….. 230
12.3 Return to healthier work: the process for B.F……. 235
12.3.1 Immediately implementable
modifications in work conditions……… 236
12.3.2 Outreach: initial efforts towards
improving work organization………….. 240

Chapter 13 Scientist with Bipolar Disorder: Seventh Clinical

Case Study………………………………………... 241
13.1 The case: Dr. A. has bipolar disorder…………….. 242
13.1.1 Objective findings……………………... 243
13.2 Dr. A.’s work situation: insights from the OSI...… 244
xiv Contents

13.3 What are the feasible options for Dr. A. vis-à-vis

the work environment? …...……………………… 246
13.4 Healthy work for scientists?.................................... 250

Chapter 14 A Dysphoric Academic Physician near Formal

Retirement Age: Concluding Case Study………... 253
14.1 Dr. L. is nearing formal retirement age and is
dysphoric....................................………...……….. 254
14.2 Dr. L.’s work situation: insights from the OSI…... 255
14.3 The transition process for Dr. L………………….. 259
14.4 Comments and further thoughts….………………. 260

Part III  A New Clinical Approach to Neuropsychiatry

Focusing upon the Work Environment……..……. 263

Chapter 15 The Need for a New Subspecialty:

Occupational Neuropsychiatry…………………… 265
15.1 An occupational neuropsychiatry paradigm:
mental health disorders as potential “occupational
sentinel health events” …………………………… 267
15.2 A larger framework for the occupational
neuropsychiatrist…………………………………. 268
15.3 Can workplace modifications suggested by the
clinician for individual patients help inform
workplace intervention trials? …………………… 270

Chapter 16 Perspectives towards a Humane Work

Environment: A Clinical View…………………... 271

Appendices ……………………………………………………. 275

Appendix A Diagnostic Criteria for Selected Mental,

Behavioral and Somatic Disorders……………….. 277
Section 1 Diagnostic criteria for selected mental and
behavioral disorders based on the ICD-10……..… 278
 Contents xv

Section 2 Classification based on the ICD-10 of selected

somatic disorders…………………………………. 291
Section 3 Description of selected mental, behavioral and
somatic disorders not yet included in the ICD-10... 293

Appendix B Completed Physician-Specific OSI Questionnaire

and Score Sheet…………………………………... 297

Bibliography………………………….……………...……............. 329

Index………………………………….……………….…............... 373